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North Toronto OHT Self-Assessment Appendices Vf.Pdf North Toronto Health Collaboration Ontario Health Team Appendices May 15, 2019 Self-Assessment Submission List of Appendices 1. Ontario Health Team: Submitting Members (slide 3) 2. North Toronto Health Collaboration: Vision (slide 4) 3. North Toronto Health Collaboration: Guiding principles (slide 5) 4. North Toronto Health Collaboration: Goals (slide 6) 5. North Toronto Health Collaboration: Statement of Intent (slides 7-9) 6. North Toronto Health Collaboration: Partnership List (slide 10) 7. Geographic Catchment (slide 11) 8. Primary Care and Community Committee (PCCC): Purpose & Membership (slide 12) 9. Seamless Care Optimizing the Patient Experience (SCOPE) (slide 13) 10. North Toronto Sub-Region Advisory Council: Membership List (slides 14-15) 11. North Toronto Sub-Region Advisory Council: Terms of Reference (slide 16) 12. Palliative Care Journey Committee: Terms of Reference (slide 17) 13. Palliative Care Journey Committee: Network of Partners (slide 18) 14. Sunnybrook Data: Seniors (slides 19-26) 15. North Toronto Neighbourhood-level Data (slides 27-31) 16. North Toronto Neighbourhood Care (slides 32-34) 17. Patient, Family, and Caregiver Engagement Committees and Activities (slide 35) 18. North Toronto Areas of Activity (slide 36) 19. Building & Integrated Primary Care in Toronto (slide 37) 2 1. Ontario Health Team: Submitting Members 3 2. North Toronto Health Collaboration: Vision • Our vision is to become one connected system of health care for people living and seeking care in North Toronto* • This means working together to connect a complete continuum of care that meets the needs of local citizens • In the eyes of our community, care will be simple to access, it will be coordinated, and providers will communicate as One Team • We are committed to coordinating care around the people in need of care, not providers • We recognize that this has yet to be achieved in Ontario and we are committed to learning how to achieve this • As we move forward, we will be guided by our shared principles *While we are connecting care within the natural catchment area of North Toronto, we are doing so in a way that: • Does not create boundaries (real or perceived) that would limit peoples’ access • Respects the multiple accountabilities that we collectively hold, such as the care we provide beyond North Toronto 4 3. North Toronto Health Collaboration: Guiding principles • We are guided by the needs of communities and the people we serve (community over organization) • Build a system that responds to what we have heard • Respectfully engage clients / patients and communities • Respect diversity (guided by the citizen voice) and maximize equity (inform investments) • Success will require strong and engaged leadership of the partnership / network • Implementation will be underpinned by a willingness and commitment to learning and continuous improving (rapid adaptation) • This is an evolving / evolutionary process • Development is evidence-informed and will be supported with timely evaluation • We will capitalize and build on what has been accomplished to date • Adopt values defined by the Local Collaborative (person-centred, transparent, cooperative, inclusive, leading change) • Process will be inclusive and transparent both within the participant membership and with our partners in our communities • Will be implemented through a collaborative / participatory model and on a voluntary basis • This is a system approach • Committed to consistency in messaging and how we communicate 5 4. North Toronto Health Collaboration: Goals 1. Everyone is able to access and 4. Every health care provider will be 6. Performance measures will: navigate health care in the North connected as part of one system of • Reflect population health status • Access to care that meets needs care, including primary care • Support self navigation and health and health equity literacy • Providers will work as one team • Reflect client and community and one brand will be built experience 2. Every person will have access to primary and team-based care when • Providers will work as one team • Track value needed • Communication will happen in a • Show improvement in what we • All residents of North Toronto will timely manner have the opportunity to be rostered, do enrolled, or attached to primary care • Platforms will be interoperable Transparent access targets will be • All residents will have choice and flexibility in where they can receive published primary care 5. Leadership and governance model • Primary care will be available when people need it and urgent care will will reflect shared accountability 7. Providers will be jointly committed be offered and collaboration across primary to continuous improvement and care, community-based care, and connecting with social services 3. People and providers will be satisfied hospital care with the coordination available to them • One collaborative Quality • Will be achieved by building on the • Shared accountability will be Improvement Plan (cQIP) will be community assets available in North established published Toronto • Gains and risks will be shared • The network will actively engage across providers partners to contribute to improving social determinants of health 8. Investment will be targeted to meeting need 6 5. North Toronto Health Collaboration: Statement of Intent (Part 1) 7 5. North Toronto Health Collaboration: Statement of Intent (Part 2) 8 5. North Toronto Health Collaboration: Statement of Intent (Part 3) 9 6. North Toronto Health Collaboration: Partnership List • Bolded partners have signed the Statement of Intent to be part of ‘North Toronto Health Collaboration’ • Non-bolded organizations have shown interest and / or we feel there is alignment with the mission / purpose of the North Toronto OHT and we hope to engage further with • We recognize our partnership list will grow to reflect our governance model; as such not all organizations could be listed at this time Citizen / Patient Hospital & Community Support Home Care & Primary Care Community MH&A Other Advisor Ambulatory Services Community Support Leslie Millrod Unison LOFT Baycrest Hospital SPRINT Senior Care Home & Toronto Paramedic Citizen Advisor Michelle Joseph, CEO Heather McDonald, CEO William Reichman, CEO Stacy Landau, CEO Community Care Services Tess Romain, Acting CEO Vibrant Healthcare Bellwood Health Services Sunnybrook Alzheimer’s Society SE Health Simone Atungo, CEO Joe Manget, CEO Andy Smith, CEO of Toronto Shirley Sharkee, CEO Scott Russell, CEO SHSC Dept. Family & Skylark Bellwoods Centres VHA Home Healthcare Community Medicine Lydia Sai-Chew, CEO for Community Living Carol Annett, CEO Dr. Karen Fleming Lori Holloway, CEO Centres d'Accueil Héritage Dr. Yoell Abels Barbara Ceccarelli Forest Hill Family Health Centre Directrice générale / Executive Director Dr. Jocelyn Charles Physician advisor, Primary Care PACE Independent Living TC LHIN Laura Viser, Executive Director, Interprofessional Primary Care Team Baycrest Hospital Integrated Community Care Team Baycrest Hospital Sunnybrook Academic FHT 10 7. Geographic Catchment 203,700 Area: 39 km2 13 City of Toronto Neighbourhoods Population Density: 5,244.4 persons per km2 Males: 46.2% Females: 53.9% % Seniors (ages 65+): 16.0% (32,615 individuals) 11 8. Primary Care and Community Committee (PCCC): Purpose & Membership The North Toronto PCCC works proactively with Primary Care to create a network that identifies population and primary care needs and responds by engaging health and social system partners to co-develop innovative direct care service delivery models. Member Name Address Email Physician Model Dr. Yoel Abells 491 Eglinton Avenue West 2nd Floor, Toronto ON M5N 1A8 [email protected] FHG (PCCL/Chair) Sunnybrook Health Sciences Centre Room C114 Dr. Dan Cass [email protected] NA 2075 Bayview Avenue, Toronto ON M4N 3M5 Toronto Central Local Health Integration Network Wilfred Cheung [email protected] NA 250 Dundas Street West, Suite 305, Toronto, ON M5T 2Z5 Sunnybrook Health Sciences Centre Room A100 Dr. Lisa Del Giudice [email protected] FHT/FHO 2075 Bayview Avenue, Toronto ON M4N 3M5 Sunnybrook Health Sciences Centre Dr. Karen Fleming [email protected] FHO 2075 Bayview Avenue, Toronto ON M4N 3M5 Dr. Steven Gottesman 491 Lawrence Avenue West Suite 100, Toronto ON M5M 1C7 [email protected] FHO Stacy Landau SPRINT Senior Care, 140 Merton Street, 2nd Floor, Toronto, ON M4S 1A1 [email protected] NA Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Kitty Liu [email protected] NA Toronto ON M4N 3M5 Dr. Rivian Miller 245 Eglinton Avenue East, Toronto ON M4P 3B7 [email protected] FHG Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Kittie Pang [email protected] NA Toronto ON M4N 3M5 Unison Health & Community Services, 1651 Keele Street,Toronto ON M6M Dr. Mary Romaniuk [email protected] CHC 3W2 LOFT Community Services, 15 Toronto Street, 9th floor, Toronto ON, M5C Debra Walko [email protected] NA 2E3 Toronto Central Local Health Integration Network Lindsay Wingham-Smith [email protected] NA 425 Bloor Street East, Suite 201, Toronto, ON M4W 3R4 Dr. Patrick Wong Vibrant Healthcare Alliance, 2398 Yonge Street, Toronto ON M4P 2H4 [email protected] CHC 12 9. Seamless Care Optimizing the Patient Experience (SCOPE) • SCOPE (Seamless Care Optimizing The Patient Experience) is a virtual interprofessional health team that supports primary care providers through a single point of access.
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